Consult-Liaison Education Medicine

Personality Disorders (II).

Now that we know how personality disorders are defined, we can discuss specific types of personality disorders.

DSM-4 divides personality disorders into three “clusters”: A, B, and C. These clusters are based on “descriptive similarities”. The authors make an important comment:

It should be noted that this clustering system, although useful in some research and educational situations, has serious limitations and has not been consistently validated.

This means that these “clusters” can be useful in theory, but may be irrelevant, illogical, and a bunch of hooey in application.

Furthermore, DSM comments:

… individuals frequently present with co-occurring Personality Disorders from different clusters.

(The world of cookies would be easier to understand if there were only butter, fruit, and nut cookies, but sometimes you end up with a platter of apricot and pistachio cookies, hamantash cookies, and shortbread and chocolate chip cookies.)

The language used to describe the clusters of personality disorders (and the personality disorders themselves) can be interpreted as criticism. Instead of recognizing the clustering system as a heuristic, people might overlook its “serious limitations” and assume that the clustering system provides definitions.

This can lead to the unfortunate practice of people saying things like, “He’s definitely personality disordered,” or “She’s such a borderline,” when, in fact, no personality disorder is present and people actually mean, “I’m getting so annoyed with that person”.[1. You feel what you feel. Own it. That will make you a more effective clinician. If you don’t acknowledge your own emotions, they will come out in some other way that might affect your behavior in ways you don’t like.]

You can see how this starts upon reading how most medical students learn about the three clusters of personality disorders:

“Here’s a mnemonic for the personality disorders. Remember the three ‘W’s: Weird, Wacky, and Worried. Cluster A is ‘weird’, cluster B is ‘wacky’, and cluster C is ‘worried’. That’ll help you keep the personality disorders straight on your shelf exam.”

So, after that entire preamble, here are the verbatim DSM definitions of the three clusters of personality disorders:

Cluster A includes the Paranoid, Schizoid, and Schizotypal Personality Disorders. Individuals with these disorders often appear odd or eccentric.

That’s where the “weird” comes from.

Cluster B includes the Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders. Individuals with these disorders often appear dramatic, emotional, or erratic.

And that’s where the “wacky” comes from.

Individuals with “cluster B traits” or personality disorders within this cluster most commonly come to clinical attention because their behaviors often cause distress both to themselves and those around them.

Cluster C includes the Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders. Individuals with these disorders often appear anxious or fearful.

And there’s “worried”.

I’m not a linguist, but it is easy to see here how the use of language can greatly affect the way we think about events, behavior, people, etc. When we distill personality disorders down to single words, we forget the other criteria for personality disorders (the “enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”).

That mental shortcut can significantly affect how we treat patients with these conditions. This is why I try to remain vigilant in what words I use to describe patients both to myself and others.

Next: We’ll start going through the specific personality disorders and interesting data associated with them as I review the literature.